title: Building social currency with foreskin cuts: a coping mechanism of Papua New Guinea health workers and the implications for new programmes.
abstract: BACKGROUND
  Recent research as part of a multi-disciplinary investigation on the acceptability and impact of male circumcision for HIV prevention in Papua New Guinea (PNG) has shown that health workers (HWs) undertake unauthorized forms of penile cutting practices in public health facilities or in community settings, at times within a traditional context. Participation in these activities shares common features with coping mechanisms, strategies used by HWs to alleviate the burden of unsatisfactory living and working conditions. Coping mechanisms, however, are typically described as motivated by economic advantage, but in PNG evidence exists that the behaviours of HWs are also influenced by opportunities for social capital.
  
  
  METHODS
  Twenty-five in-depth interviews (IDIs) were completed with a variety of HWs from 2009 until 2011 and were triangulated with findings from 45 focus group discussions and 82 IDIs completed with community members as part of a wider qualitative study. Thematic analysis examined HW participation in unauthorized penile cutting services.
  
  
  RESULTS
  The emergence of unauthorized practices as a coping mechanism in PNG is compelled by mutual obligations and social capital arising from community recognition and satisfaction of moral, professional and cultural obligations. Using the example of unauthorized penile cutting practices amongst HWs in PNG, the research shows that although economic gains are not explicitly derived, evidence exists that they meet other community and socio cultural responsibilities forming a social currency within local traditional economies.
  
  
  CONCLUSIONS
  Coping mechanisms create an opportunity to extend the boundaries of a health system at the discretion of the HW. Fragile health systems create opportunities for coping mechanisms to become institutionalized, pre-empting appropriate policy development or regulation in the introduction of new programmes. In order to ensure the success of new programmes, the existence of such practices and their potential implications must be addressed within programme design, and in implementation and regulation.
authors.affiliation: Australian Centre for International & Tropical Health, School of Population Health, The University of Queensland, Herston Road, Herston, Queensland 4006, Australia, Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research, PO Box 60, Goroka Eastern Highlands Province 441, Papua New Guinea, Public Health Interventions Research Group, The Kirby Institute, University of New South Wales, 45 Beach Street Coogee, New South Wales 2034, Australia and International HIV Research Group, School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia anna.tynan@uqconnect.edu.au.
authors.forename: Anna
authors.initials: A
authors.lastname: Tynan
authors.affiliation: Australian Centre for International & Tropical Health, School of Population Health, The University of Queensland, Herston Road, Herston, Queensland 4006, Australia, Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research, PO Box 60, Goroka Eastern Highlands Province 441, Papua New Guinea, Public Health Interventions Research Group, The Kirby Institute, University of New South Wales, 45 Beach Street Coogee, New South Wales 2034, Australia and International HIV Research Group, School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia Australian Centre for International & Tropical Health, School of Population Health, The University of Queensland, Herston Road, Herston, Queensland 4006, Australia, Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research, PO Box 60, Goroka Eastern Highlands Province 441, Papua New Guinea, Public Health Interventions Research Group, The Kirby Institute, University of New South Wales, 45 Beach Street Coogee, New South Wales 2034, Australia and International HIV Research Group, School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia.
authors.forename: Andrew
authors.initials: A
authors.lastname: Vallely
authors.affiliation: Australian Centre for International & Tropical Health, School of Population Health, The University of Queensland, Herston Road, Herston, Queensland 4006, Australia, Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research, PO Box 60, Goroka Eastern Highlands Province 441, Papua New Guinea, Public Health Interventions Research Group, The Kirby Institute, University of New South Wales, 45 Beach Street Coogee, New South Wales 2034, Australia and International HIV Research Group, School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia Australian Centre for International & Tropical Health, School of Population Health, The University of Queensland, Herston Road, Herston, Queensland 4006, Australia, Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research, PO Box 60, Goroka Eastern Highlands Province 441, Papua New Guinea, Public Health Interventions Research Group, The Kirby Institute, University of New South Wales, 45 Beach Street Coogee, New South Wales 2034, Australia and International HIV Research Group, School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia.
authors.forename: Angela
authors.initials: A
authors.lastname: Kelly
authors.affiliation: Australian Centre for International & Tropical Health, School of Population Health, The University of Queensland, Herston Road, Herston, Queensland 4006, Australia, Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research, PO Box 60, Goroka Eastern Highlands Province 441, Papua New Guinea, Public Health Interventions Research Group, The Kirby Institute, University of New South Wales, 45 Beach Street Coogee, New South Wales 2034, Australia and International HIV Research Group, School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia.
authors.forename: Martha
authors.initials: M
authors.lastname: Kupul
authors.affiliation: Australian Centre for International & Tropical Health, School of Population Health, The University of Queensland, Herston Road, Herston, Queensland 4006, Australia, Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research, PO Box 60, Goroka Eastern Highlands Province 441, Papua New Guinea, Public Health Interventions Research Group, The Kirby Institute, University of New South Wales, 45 Beach Street Coogee, New South Wales 2034, Australia and International HIV Research Group, School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia.
authors.forename: Richard
authors.initials: R
authors.lastname: Naketrumb
authors.affiliation: Australian Centre for International & Tropical Health, School of Population Health, The University of Queensland, Herston Road, Herston, Queensland 4006, Australia, Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research, PO Box 60, Goroka Eastern Highlands Province 441, Papua New Guinea, Public Health Interventions Research Group, The Kirby Institute, University of New South Wales, 45 Beach Street Coogee, New South Wales 2034, Australia and International HIV Research Group, School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia.
authors.forename: Herick
authors.initials: H
authors.lastname: Aeno
authors.affiliation: Australian Centre for International & Tropical Health, School of Population Health, The University of Queensland, Herston Road, Herston, Queensland 4006, Australia, Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research, PO Box 60, Goroka Eastern Highlands Province 441, Papua New Guinea, Public Health Interventions Research Group, The Kirby Institute, University of New South Wales, 45 Beach Street Coogee, New South Wales 2034, Australia and International HIV Research Group, School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia.
authors.forename: Peter
authors.initials: P
authors.lastname: Siba
authors.affiliation: Australian Centre for International & Tropical Health, School of Population Health, The University of Queensland, Herston Road, Herston, Queensland 4006, Australia, Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research, PO Box 60, Goroka Eastern Highlands Province 441, Papua New Guinea, Public Health Interventions Research Group, The Kirby Institute, University of New South Wales, 45 Beach Street Coogee, New South Wales 2034, Australia and International HIV Research Group, School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia.
authors.forename: John M
authors.initials: JM
authors.lastname: Kaldor
authors.affiliation: Australian Centre for International & Tropical Health, School of Population Health, The University of Queensland, Herston Road, Herston, Queensland 4006, Australia, Sexual & Reproductive Health Unit, Papua New Guinea Institute of Medical Research, PO Box 60, Goroka Eastern Highlands Province 441, Papua New Guinea, Public Health Interventions Research Group, The Kirby Institute, University of New South Wales, 45 Beach Street Coogee, New South Wales 2034, Australia and International HIV Research Group, School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia.
authors.forename: Peter S
authors.initials: PS
authors.lastname: Hill
mesh_terms: D000223:Adaptation, Psychological; D002944:Circumcision, Male; D003153:Community Health Services / Q000458:organization & administration / Q000592:standards; D003150:Community Health Workers / Q000523:psychology / Q000706:statistics & numerical data; D003469:Culture; D017144:Focus Groups; D052816:Foreskin / Q000293:injuries*; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D010219:Papua New Guinea
keywords: Coping mechanisms; Papua New Guinea; health system; penile foreskin cutting; social capital; unauthorized practices